Bülent Bakar

Pregnancy associated quadriparesis in a patient with Von-Hippel Lindau disease

Sirs: Von-Hippel Lindau (VHL) disease is a dominantly inherited disease characterized by hemangioblastomas of the central nervous system, retina and viscera and is also associated with cysts and tumors of the viscera [1, 4, 7]. The course of the disease during pregnancy is not well established, but reports in the literature favor a benign course during that period. This case report presents a patient with VHL and recurrent deterioration in the neurological status during her pregnancies. A 34-year-old woman, pregnant for the third time, was admitted to our medical center at 33 weeks gestation with complaints of progressive quadriparesis, urinary and fecal incontinence. Her initial complaints had started 12 years previously, during her second pregnancy, with severe pain radiating to upper and lower extremities followed by paresthesia and weakness in the right leg. Her symptoms were partially relieved during the post-partum period. Two years after the onset of initial complaints, she experienced a sudden onset of weakness progressing to total quadriplegia, within 24 hours. Computed tomography, performed in another medical center, revealed a hemorrhagic cervical mass lesion. She was operated for this lesion, but the nature of the mass was not established by pathological examination. In the post-operative period, following neuro-rehabilitation, she was ambulatory with aid and had partial motor deficit in her upper extremities. During the first trimester of her third pregnancy, progression in lower extremity weakness and severe numbness below the nipple level involving the whole body occurred. She was totally bed-ridden and complained of fecal and urinary incontinence at the end of second trimester. Upper extremity weakness also progressed during the third trimester. No report of consanguinity or family history of similar disease was present. In her initial neurological evaluation, retinal hemangioma in the left eye, bilateral horizontal nystagmus, paraplegia, asymmetric paresis of the upper extremities, anesthesia below T10 level, increased deep tendon reflexes and bilateral extensor plantar responses were detected. Routine laboratory examination including complete blood count, renal and liver function tests, serum electrolytes, electrocardiography and chest radiographs were within normal limits. In her cranial and spinal MRI, multiple lesions consistent with hemangioblastomas were detected in the cerebellum, and at upper cervical and lower thoracic levels (Figs. 1 and 2). As these findings were suggestive of VHL, the patient was evaluated further for other systemic involvement. By abdominal ultrasonograpy, bilateral renal multiple cysts and hepatic hemangioma were detected. Multiple pancreatic cysts were also seen in abdominal computed tomography examination. No adrenal pathology was evident and urine measurement of catecholamines and their metabolites were within normal limits. The patient gave birth to a male fetus by vaginal delivery with an Apgar score of 0, one week after hospitalization. No abnormality was found in the autopsy of the fetus. The patient declined further medical examination and was disLETTER TO THE EDITORS

Intravascular lymphoma masquerading as multiembolic stroke developing after coronary artery by-pass surgery.

Background:Intravascular lymphoma (IVL) is a very rare non-Hodgkin type lymphoproliferative disorder characterized by neoplastic growth of lymphoid cells within the lumen of capillaries, small veins, and arterioles. The neoplastic cells cannot reach the parenchyma because of the loss of adhesion molecules during malignant transformation. Multifocal vascular occlusions caused by proliferation of malignant lymphocytes in the lumen result in diffuse thrombosis and tissue infarction. The clinical symptoms of the disease are dependent on the specific organ involvement which most often includes the central nervous system and skin. Neurologic presentation includes focal sensory or motor deficits, altered sensorium, rapidly progressive dementia, seizures, ataxia, and vertigo. Case Report:We report a patient with IVL whose symptoms developed on the second postoperative day of coronary artery-bypass surgery imitating a multiembolic stroke. Magnetic resonance imaging showed widespread ischemic subcortical lesions. The patients clinical status worsened irrespective of supportive medical treatment. The diagnosis was established by autopsy. Conclusion:IVL may mimic ischemic stroke. IVL is not often diagnosed before death because of the intravascular growth pattern of the tumor cells and a fulminant clinical course. IVL may be considered in the differential diagnosis of ischemic stroke patients with progressive worsening despite medical management.

Effects of low-dose methotrexate in spinal cord injury in rats.

BACKGROUND This study was designed to evaluate the possible protective effects of low-dose methotrexate in the spinal cord injury (SCI) in rats. METHODS Thirty-seven Wistar albino rats were used in the present study. Except for the animals of the Sham group, all animals were divided into two main groups, which were used in acute and subacute stage investigations. Then, thoracal laminectomy was performed, and except for the Sham group, SCI was induced using a temporary aneurysm clip. After clip compression, the experimental material (methotrexate or methylprednisolone) was administered intraperitoneally, except in the Sham and Control groups. Then, the spinal cords were removed to evaluate the SCI histopathologically and biochemically at the scheduled date. RESULTS Neither experimental material was shown to reduce the histopathological grade in either stage of SCI. Low-dose methotrexate was shown to decrease lipid peroxidation levels only in the subacute stage of SCI. However, methylprednisolone and low-dose methotrexate could not decrease or block myeloperoxidase enzyme activation in either stage of SCI. CONCLUSION Low-dose methotrexate was effective in reducing the lipid peroxidation levels in the subacute stage of SCI, although histopathological evaluation results and myeloperoxidase levels of all groups did not support this finding at either stage.Departments of 1Neurosurgery, 2Anaestesiology and Reanimation, Kirikkale University Faculty of Medicine, Kirikkale; 3Department of Pathology, Baskent University Faculty of Medicine, Ankara; 4Department of Biochemistry, Hacettepe University Faculty of Medicine, Ankara, Turkey. Kirikkale Universitesi Tip Fakultesi, 1Norosirurji Anabilim Dali, 2Anesteziyoloji ve Reanimasyon Anabilim Dali, Kirikkale; 3Baskent Universitesi Tip Fakultesi, Patoloji Anabilim Dali, Ankara; 4Hacettepe Universitesi Tip Fakultesi, Biyokimya Anabilim Dali, Ankara.

Effects of intracisternal and intravenous dexmedetomidine on ischemia-induced brain injury in rat: a comparative study.

AIM To compare the effect of dexmedetomidine administered by intracisternal route with by intravenous route on brain tissue of rat after incomplete cerebral ischemia. MATERIAL AND METHODS Cerebral ischemia was produced by the combination of right common carotid artery occlusion and hemorrhagic hypotension during 30 minutes. Thirty minutes before the ischemia, 0.1 ml 0.9% NaCl (Group SIC, n=6) or 9 μg/kg dexmedetomidine (Group DIC, n=6) was administered into the cisterna magna. For the intravenous groups, 9 μg/kg dexmedetomidine (Group DIV, n=6) or 0.9% NaCl (Group CONTROL, n=6) 5 ml/kg/h was given in 2 hours. After 24 hours, the lipid peroxidation levels were measured in the brain tissue and plasma. Hippocampal formations were used for histopathological examination. RESULTS Intravenous dexmedetomidine produced a decrease in baseline mean arterial blood pressure and plasma glucose concentrations. There was a significant difference between the DIV group and DIC, SIC, CONTROL groups regarding the brain lipid peroxidation levels (p < 0.001, p < 0.001, p=0.001, respectively), and regarding the picnotic neuronal cell count (p < 0.001, p=0.01, p=0.009, respectively). Mean plasma lipid peroxidation levels of the DIV group was different from the DIC group (p=0.003). CONCLUSION Systemically administered dexmedetomidine had neuroprotective effect in ischemia-induced neuronal damage, but centrally administered dexmedetomidine did not.

Evaluation of the neurotoxicity of the polyethylene glycol hydrogel dural sealant.

AIM Although polyethylene glycol (PEG) is a neutral, biocompatible hydrophilic polymer recognized for its lack of interaction with biological barrier, its neurotoxicity has not been clearly identified in neurosurgery. This study is constructed to evaluate the possible neurotoxicity of a PEG hydrogel dural sealant. MATERIAL AND METHODS After a burrhole was opened in the left parietal bone of the twenty five Wistar albino rats, the dura mater and cerebral cortex were incised and the experimental material (activated polyethylene glycol and polyethylene imine) was sprayed into the burrhole. Then brain tissues were harvested for histopathological and biochemical studies at 72 hours to investigate the acute stage changes and on 15th day to evaluate the chronic stage changes. RESULTS There were statistically significant differences among the groups regarding the comparison of the values of the PMNL cell infiltration grades, gliosis and congestion in both acute and chronic stages. However, the values of the MNL cell infiltration grades, edema and fibrin formation, lipid peroxidation levels of harvested brain tissues were similar in all groups. CONCLUSION Although this study did not present the detailed histopathological and biochemical evaluation results, it indicated that the application of the PEG-based hydrogel sealant was not associated with neurotoxicity, delayed healing, or degenerative changes.

Far lateral disc herniation evaluated by coronal magnetic resonance imaging: case series.

The extent of the slice thickness in spinal axial and sagittal magnetic resonance imaging (MRI) is limited. We therefore, propose the idea of using coronal MRI to better delineate lumbar far lateral disc herniations. Six patients with coronal MR images who underwent surgery are presented in this study. Simple 2D vertebral column X-ray and MRI scans were used to diagnose the far lateral herniated disc. Intraoperative findings confirmed our preoperative MRI diagnosis in all patients. Recovery was excellent in all patients. In conclusion, coronal lumbar MRI, a simple and useful technique to reveal the nerve roots in foraminal and/or far lateral (extraforaminal) areas, is a must for accurate diagnosis of foraminal and/or far lateral lumbar disc herniations.

An Evaluation of the Quality of Sleep Before and After Surgical Treatment of Patients with Cervical Disc Herniation

Objective It has been reported in recent studies that 50-80% of patients with cervical disc hernia have concomitant sleep disorders. The aim of this study was to evaluate the quality of sleep before and after surgical treatment in patients with cervical disc hernia and to assess the effects on treatment. Methods The study included 32 patients performed discectomy and fusion with an intervertebral cage through the right anterior cervical approach. Oswestry Disability Index (ODI), Visual Analog Scale (VAS) and Pittsburgh Sleep Quality Index (PSQI) were applied to all patients preoperatively and at one month postoperatively. Results The postoperative PSQI total points and all the PSQI subscale points, the ODI and VAS scores were significantly reduced compared to the preoperative values. A positive correlation was determined between the preoperative ODI points and the PSQI total points and sleep duration, sleep latency and daytime functional loss subscale points. A positive correlation was also found between preoperative ODI points and VAS points. A positive correlation was determined between the preoperative VAS points and and the PSQI total points and sleep duration, and sleep latency subscale points. A negative correlation was determined between the postoperative ODI and the daytime functional loss subscale points. Conclusion The results of the study showed that in patients with cervical disc hernia, sleep quality and daytime functionality were negatively affected by severity of pain that limited daily activities. Bringing the pain under control with surgical treatment was observed to increase sleep quality. It can be concluded that when planning treatment for these patients, it should be taken into consideration that there could be a sleep disorder in addition to the complaints and symptoms such as pain, hypoestesia and loss of strength.

Evaluation of the systemic antiinflammatory effects of levosimendan in an experimental blunt thoracic trauma model

BACKGROUND Blunt thoracic injury often leads to pulmonary contusion and the development of acute respiratory distress syndrome, which carries a high risk of morbidity and mortality, originating from the local and systemic inflammatory states. This study aimed to investigate the local and systemic antiinflammatory effects of levosimendan in rat models of blunt chest trauma. METHODS A total of 32 Wistar albino rats were randomly assigned to one of the following four groups: control, sham, low-dose levosimendan (LDL) (5 µg/kg loading dose for 10 min and 0.05 µg/kg/min intravenous infusion), and high-dose levosimendan (HDL) (10 µg/kg loading dose for 10 min and 0.1 µg/kg/min intravenous infusion). Blunt chest trauma was induced, and after 6 h, the contused pulmonary tissues were histopathologically and immunohistopathologically evaluated, serum TNF-α, IL-1ß, IL-6, and NO levels were biochemically evaluated. RESULTS The mean arterial pressure was low throughout the experiment in the LDL and HDL groups, with no statistically difference between the groups. Levosimendan reduced the alveolar congestion and hemorrhage, which developed after inducing trauma. Neutrophil infiltration to the damaged pulmonary tissue was also reduced in both the LDL and HDL groups. In rats in which pulmonary contusion (PC) was observed, increased activation of nuclear factor kappa B was observed in the pulmonary tissue, and levosimendan did not reduce this activation. Both high and low doses of levosimendan reduced serum IL-1ß levels, and high doses of levosimendan reduced IL-6 and NO levels. TNF-α levels were not reduced. CONCLUSION In conclusion, the results showed that in a rat model of PC, the experimental agent levosimendan could reduce neutrophil cell infiltration to damaged pulmonary tissues and the systemic expressions of some cytokines (IL-1ß, IL-6, and NO), thereby partially reducing and/or correcting pulmonary damage. Systemic inflammatory response that occurs after trauma could also be reduced.

HİDROSEFALİLİ BİR HASTADA VENTRİKÜLOPERİTONEAL ŞANT KATETERİNİN DİSTAL UCUNUN İNGUİNAL HERNİ KESESİNE MİGRASYONU

Literaturde ventrikuloperitoneal (VP) sant kataterinin intestinal perforasyon, inguinal herni, peritonit gibi abdominal komplikasyonlara neden olabilecegi bildirilmistir. Hidrosefali nedeniyle VP sant takilmis 2 aylik erkek hastanin klinik takibinde, sant ameliyatindan otuz gun sonra sol kasiginda sislik saptandi. Yapilan abdominal ultrasonografi ve direkt grafi tetkiklerinde hastanin sol skrotumu icerisinde VP sant kateterinin distal ucunun izlenmesi uzerine hasta Cocuk Cerrahisi Bolumu tarafindan degerlendirildi. Hastaya sol inguinoskrotal herni tanisi koyularak ameliyat edildi. Kateter ucu karin icerisine redukte edilerek yuksek ligasyon ile inguinal herni onarimi yapildi. Hastanin ameliyat sonrasi uc aylik takibi sonunda nuks ve/veya komplikasyon izlenmedi. Sonuc olarak VP sant takilan hastalarda inguinoskrotal komplikasyonlar akilda tutulmalidir. VP sant ameliyati sonrasi kasik bolgesindeki sislikler inguinal herni acisindan degerlendirilmeli ve erken tani ve tedavi icin aile bilgilendirilmelidir.

The effect of low-dose methotrexate on autologous fat graft survival.

BACKGROUND/AIM The survival of autologous fat graft tissue is dependent on various factors such as vascularization and inflammation. The aim of the present study was to evaluate the possible beneficial effects of low-dose methotrexate (LD-MTX) on fat graft volume and survival. MATERIALS AND METHODS A total of 13 male Wistar albino rats were divided into two groups, a control group and an LD-MTX group. An autologous fat graft obtained from the inguinal region of each rat was transferred to its back. LD-MTX was administered intraperitoneally in the LD-MTX group once a week for 4 weeks after the surgical procedure. The control group underwent surgery but was not administered MTX. Fat grafts were harvested for analyses. RESULTS The results showed that 2 months postoperatively the fat graft weights of the control and LD-MTX groups were not significantly different. In addition, the vascularity of the grafts was higher in the LD-MTX group than it was in the control group. The mean lipid peroxidation levels were essentially the same in the two groups, but myeloperoxidation was significantly lower in the LD-MTX group than it was in the other group. CONCLUSION The results showed that LD-MTX administration may not preserve the quality and volume of transplanted fat tissue in rats.